Effectiveness and Safety of Procalcitonin-Guided Antibiotic Therapy in Lower Respiratory Tract Infections in “Real Life”：An International, Multicenter Poststudy Survey (ProREAL)

Werner C. Albrich, MD, MSCR; Frank Dusemund, MD; Birgit Bucher; Stefan Meyer; Robert Thomann, MD; Felix Kühn, MD; Stefano Bassetti, MD; Martin Sprenger, MD; Esther Bachli, MD; Thomas Sigrist, MD; Martin Schwietert, MD; Devendra Amin, MD; Pierre Hausfater, MD, PhD; Eric Carre, MD; Jacques Gaillat, MD; Philipp Schuetz, MD, MPH; Katharina Regez, RN; Rita Bossart, RN, PhD; Ursula Schild, RN; Beat Mueller, MD; for the ProREAL Study Team

Arch Intern Med. 2012;172(9):715-722. doi:10.1001/archinternmed.2012.770.

ABSTRACT

Background  In controlled studies, procalcitonin (PCT) has safely and effectively reduced antibiotic drug use for lower respiratory tract infections (LRTIs). However, controlled trial data may not reflect real life.

Methods  We performed an observational quality surveillance in 14 centers in Switzerland, France, and the United States. Consecutive adults with LRTI presenting to emergency departments or outpatient offices were enrolled and registered on a website, which provided a previously published PCT algorithm for antibiotic guidance. The primary end point was duration of antibiotic therapy within 30 days.

Results  Of 1759 patients, 86.4% had a final diagnosis of LRTI (community-acquired pneumonia, 53.7%; acute exacerbation of chronic obstructive pulmonary disease, 17.1%; and bronchitis, 14.4%). Algorithm compliance overall was 68.2%, with differences between diagnoses (bronchitis, 81.0%; AECOPD, 70.1%; and community-acquired pneumonia, 63.7%; P < .001), outpatients (86.1%) and inpatients (65.9%) (P < .001), algorithm-experienced (82.5%) and algorithm-naive (60.1%) centers (P < .001), and countries (Switzerland, 75.8%; France, 73.5%; and the United States, 33.5%; P < .001). After multivariate adjustment, antibiotic therapy duration was significantly shorter if the PCT algorithm was followed compared with when it was overruled (5.9 vs 7.4 days; difference, −1.51 days; 95% CI, −2.04 to −0.98; P < .001). No increase was noted in the risk of the combined adverse outcome end point within 30 days of follow-up when the PCT algorithm was followed regarding withholding antibiotics on hospital admission (adjusted odds ratio, 0.83; 95% CI, 0.44 to 1.55; P = .56) and regarding early cessation of antibiotics (adjusted odds ratio, 0.61; 95% CI, 0.36 to 1.04; P = .07).

Conclusions  This study validates previous results from controlled trials in real-life conditions and demonstrates that following a PCT algorithm effectively reduces antibiotic use without increasing the risk of complications. Preexisting differences in antibiotic prescribing affect compliance with antibiotic stewardship efforts.